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Advances in measurement and intervention for excessive drinking
Editorials and Commentary
Advances in Measurement and Intervention for Excessive Drinking Ralph Hingson, ScD
I
n 2002, the National Advisory Council of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) released the first National Institute of Health report on the magnitude of college drinking problems in the United States. The report also explored which interventions—identified through rigorous research— can reduce college drinking problems. According to the report, annually there are at least 1400 college students aged 18 to 24 years who die from alcohol-related unintentional injuries, and almost 1100 of these are alcohol-related traffic deaths.1,2 Of the 8 million college students that age in the United States, over 3 million rode with a drinking driver in the previous year and 2 million drove under the influence of alcohol. Annually, a total of 500,000 college students aged 18 to 24 are injured because of their drinking. Of note, the harms associated with college drinking are not restricted to the drinkers themselves. Nearly half of the traffic deaths involving 18- to 24-year-old drinking drivers are persons other than the drinking driver. Further, annually more than 600,000 of 18- to 24-year-old college students are hit or assaulted by another drinking college student, and 70,000 to 80,000 college students that age experience sexual assaults or date rapes perpetrated by drinking college students.1,2 Because college drinking is harmful to other people, colleges and the communities in which they reside have an obligation to implement programs and policies to protect students and others from harm that may arise from excessive college student drinking and risky or violent behavior when drinking. The NIAAA report identified several individual-oriented counseling strategies that can reduce drinking and problems associated with excessive drinking.1,3 However, for these counseling strategies to benefit large numbers of students, widespread screening programs contacting most, if not all, college students will be needed. To date, few colleges or universities have embarked on widespread screening. Even if all college students were screened for alcohol problems and offered counseling as needed, the com-
From the Boston University Center to Reduce Alcohol Problems Among Young People, Boston, Massachusetts Address correspondence to: Ralph Hingson, ScD, 5636 Fishers Lane, Room 2077, MSC 9304, Bethesda MD 20892-9304. E-mail: [email protected]
munity environments in which colleges are located would still create drinking problems among college students. In 2003, the Centers for Disease Control and Prevention conducted the Youth Risk Behavior Survey,4 a national random-sample survey of high school students. Results of that survey indicated that, of the over 14 million high school students in the United States, 1 million drank five or more drinks on an occasion at least six times in the past 30 days. If a 170-pound man drank five or more drinks in a 2-hour period on an empty stomach, he would reach a blood alcohol level of 0.08% and would be considered legally intoxicated in every state.5 The typical high school female who weighs less would reach even higher blood alcohol content. Compared to nondrinking students, high school youth who engage in this pattern of frequent drinking to intoxication disproportionately engage in numerous behaviors that pose risk to themselves and others. In the month prior to the survey, they were much more likely to: ● ● ● ● ● ● ● ● ● ● ●
Drive after drinking (61% vs 0%) Ride with a drinking driver (80% vs 13%) Never wear safety belts (18% vs 4%) Carry a gun (24% vs 2%) Be injured in a fight (17% vs 2%) Use marijuana (71% vs 6%) and cocaine (22% vs 4%) Be forced to have sex (18% vs 3%) Have had sex with six or more partners (32% vs 3%) Have been or made someone pregnant (13% vs 2%) Earn mostly D’s and F’s in school (13% vs 4%) Have been injured in a suicide attempt (10% vs 1%)4
The average age when youth start to drink may be declining in the United States.6 Yet the younger people are when they begin to drink, the more likely they are to engage in dangerous drinking practices both in high school4 and college.4,7,8 High school students who began drinking prior to age 13 were seven times more likely to be frequent heavy drinkers (more than five drinks per occasion, more than six times per month) in high school than those who waited until age ⱖ17 to start drinking.4 According to the National College Alcohol Survey among college students aged ⱖ18, those who were first intoxicated before age 13—relative to those first intox-
Am J Prev Med 2004;27(3) © 2004 American Journal of Preventive Medicine • Published by Elsevier Inc.
0749-3797/04/$–see front matter doi:10.1016/j.amepre.2004.06.009
261
icated at age ⱖ19 —were three times more likely to be alcohol dependent in college (8% of drinkers in college are alcohol dependent); 1.6 times more likely to drive after consuming five or more drinks and to ride with a driver who was high or drunk; twice as likely to be so seriously injured after drinking that they required medical attention; and twice as likely to have unplanned and unprotected sex.7,8 These relations with risky behaviors among college students were observed even after controlling for age, gender, race/ethnicity, marital status, alcohol dependence, parental drinking history, and age of first cigarette and marijuana use. Furthermore, although a higher percentage of 18- to 24-year-old college students drink heavily and drive under the influence than same-aged persons not in college, there are so many more young people not in college that they actually account for more alcoholrelated problems and deaths than the drinking college students.2 Thus, there is a clear need to change the drinking culture not only in colleges but also in surrounding communities. Environmental interventions implemented in comprehensive community programs have been found to reduce drinking- and alcohol-related assault injuries, motor vehicle crashes, and deaths9 –12 among high school– and college-aged youth. Typically, these community interventions involve multiple departments of city government, concerned private citizens and organizations, and multiple levels of education and law enforcement programs. In this issue, the article by Weitzman et al.13 examining comprehensive college/community environmental interventions is the first to identify that this type of intervention, if vigorously pursued, can reduce drinking problems specifically among college students. It can also reduce secondhand effects of alcohol perpetrated on other college students by students who engage in excessive college drinking. This careful and rigorous evaluation is the first to show positive benefits of interventions across entire college populations, not just select subgroups of students. These findings are timely because there are no indications of reductions in college drinking in the past decade, and after 15 years of decline, alcohol-related traffic deaths among 18- to 24-year-olds have increased each year since 1997.14 Future research projects should explore (1) specifically what types of interventions in these partnerships can achieve the greatest declines; (2) whether, if augmented by widespread screening and counseling programs, additional reductions can be achieved; and (3) whether people attending colleges with these campus community interventions will be less likely to exhibit drinking problems not just while in college but after they graduate. In addition, whether campus community interventions reduce problems among college-age people who are not students, but live in these college communities needs to be tested. 262
In a related article in this issue by Miller et al.,15 comparisons were made between the binge drinking results from the 1999 and 2001 Behavioral Risk Factor Surveillance System (BRFSS) survey (n ⫽353,371) and the National Survey on Drug Use and Health (NSDUH) (n ⫽87,145). The BRFSS is a random-digit-dial telephone survey with response rates of 56.7% in 1999 and 52.7% in 2001, while the NSDUH is a national in-home survey conducted by trained interviewers that includes use of an audio computer-assisted self-interview survey. The NSDUH achieved a 68.6% response rate in 1999 and 73.3% in 2001. There was good correlation between state-specific binge drinking estimates from the two surveys, Pearson correlation coefficient of r⫽0. 82, and similarities in sociodemographic characteristics of binge drinkers. However, in 1999 and 2001, the BRFSS identified only 14.8% and 14.6% of respondents as binge drinkers, compared to 21.4% and 21.7% in the NSDUH. Focusing only on phone owners in the NSDUH did not eliminate the disparity. Miller et al.15 note that the computer-assisted selfinterviews and the in-person survey approach may help improve the willingness of adults to self-report binge alcohol use. They appropriately called for testing new approaches to increase reporting of binge drinking and response rates. Pre-survey notification by mailing or media, modest financial reimbursement for time spent being interviewed, and greater emphasis on the anonymity of random-digit-dial surveys and the importance of accurate responses might increase both response rates and reports of binge drinking. While that might produce a temporary disruption in tracking the drinking trends over time, obtaining more accurate data would be beneficial. Also short callback surveys of nonrespondents to make comparisons with respondents could help assessments of the survey’s generalizability. The National Advisory Council of the NIAAA has recently defined binge drinking as five drinks for men and four for women over a 2-hour period. Questions about the duration of drinking occasions would strengthen the measurement of binge drinking in both surveys. Because the BRFSS contained many questions on related risky behaviors (e.g., driving after drinking, safety belt use, fighting, carrying weapons, and unprotected sex), it is a very valuable national resource whose usefulness would be enhanced by the suggested changes. Both the BRFSS and the NHSDUH would also be strengthened by questions used by Weitzman et al.13 in the “A Matter of Degree” evaluation that assesses secondhand effects of drinking. Without such questions, the considerable negative effects of binge drinkers’ behavior on other people cannot be fully documented and monitored over time.
American Journal of Preventive Medicine, Volume 27, Number 3
References 1. National Institute on Alcohol Abuse, Alcoholism National Advisory Council. A call to action: changing the culture of drinking at U.S. colleges. Bethesda MD: National Institutes of Health, 2002 (NIH 02-5010). 2. Hingson R, Heeren T, Zakocs R, Kopstein A, Wechsler H. Magnitude of alcohol-related mortality and morbidity among U.S. college students ages 18 –24. J Stud Alcohol 2002;63:136 – 44. 3. Larimer M, Cronce J. Identification, prevention and treatment: a review of individual-focused strategies to reduce problematic alcohol consumption by college students. J Stud Alcohol 2002;14(suppl):148 – 64. 4. Grunbaum J, Kann L, Kindum S, Williams B, Ross R, Koelbe L. Youth Risk Behavior Surveillance—United States, 2003. MMWR Morb Mortal Wkly Rep 2003;51:1– 64. 5. National Highway Traffic Safety Administration. BAC Estimator (computer program). Springfield VA: National Technical Information Service, 1992. 6. Substance Abuse and Mental Health Services Administration. Results from the 2002 National Survey on Drug Use and Health. Rockville MD: National Findings Office of Applied Studies, U.S. Department of Health and Human Services, 2003 (NHSDA Series H-22, DHHS SMN 03-3836). 7. Hingson R, Heeren T, Zakocs R, Winter M, Wechsler H. Age of first intoxication, heavy drinking, driving after drinking and risk of unintentional injury among U.S. college students. J Stud Alcohol 2003;64:23–31.
8. Hingson R, Heeren T Winter M, Wechsler H. Early age of first drunkenness as a factor in college students’ unplanned and unprotected sex attributable to drinking. Pediatrics 2003;111:34 – 41. 9. Hingson R, McGovern T, Howland J, Heeren T, Winter M, Zakocs R. Reducing alcohol-impaired driving in Massachusetts: the savings lives program. Am J Public Health 1996;86:791–7. 10. Holder H, Gruenewald PJ, Ponici WR, et al. Effects of community-based interventions on high risk driving and alcohol-related injuries. JAMA 2000;284:2341–7. 11. Wagenaar A, Murray D, Gehan J, et al. Communities mobilizing for change: outcomes from a randomized community trial. J Stud Alcohol 2000;161:85–94. 12. Hingson R, Howland J. Comprehensive community interventions to promote health: implicatios for college-age drinking problems. J Stud Alcohol 2002;14(suppl):226 – 40. 13. Weitzman ER, Nelson TF, Lee H, Wechsler H. Reducing drinking and related harms in college: evaluation of the “A Matter of Degree” program. Am J Prev Med 2004;27:187–96. 14. National Highway Traffic Safety Administration. Traffic safety facts 2002: alcohol. Washington DC: U.S. Department of Transportation, 2002. 15. Miller JW, Gfroerer JC, Brewer RD, Naimi TS, Mokdad A, Giles WH. Prevalence of adult binge drinking: a comparison of two national surveys. Am J Prev Med 2004;27:197–204.
Am J Prev Med 2004;27(3)
263
Advances in Measurement and Intervention for Excessive Drinking Ralph Hingson, ScD
I
n 2002, the National Advisory Council of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) released the first National Institute of Health report on the magnitude of college drinking problems in the United States. The report also explored which interventions—identified through rigorous research— can reduce college drinking problems. According to the report, annually there are at least 1400 college students aged 18 to 24 years who die from alcohol-related unintentional injuries, and almost 1100 of these are alcohol-related traffic deaths.1,2 Of the 8 million college students that age in the United States, over 3 million rode with a drinking driver in the previous year and 2 million drove under the influence of alcohol. Annually, a total of 500,000 college students aged 18 to 24 are injured because of their drinking. Of note, the harms associated with college drinking are not restricted to the drinkers themselves. Nearly half of the traffic deaths involving 18- to 24-year-old drinking drivers are persons other than the drinking driver. Further, annually more than 600,000 of 18- to 24-year-old college students are hit or assaulted by another drinking college student, and 70,000 to 80,000 college students that age experience sexual assaults or date rapes perpetrated by drinking college students.1,2 Because college drinking is harmful to other people, colleges and the communities in which they reside have an obligation to implement programs and policies to protect students and others from harm that may arise from excessive college student drinking and risky or violent behavior when drinking. The NIAAA report identified several individual-oriented counseling strategies that can reduce drinking and problems associated with excessive drinking.1,3 However, for these counseling strategies to benefit large numbers of students, widespread screening programs contacting most, if not all, college students will be needed. To date, few colleges or universities have embarked on widespread screening. Even if all college students were screened for alcohol problems and offered counseling as needed, the com-
From the Boston University Center to Reduce Alcohol Problems Among Young People, Boston, Massachusetts Address correspondence to: Ralph Hingson, ScD, 5636 Fishers Lane, Room 2077, MSC 9304, Bethesda MD 20892-9304. E-mail: [email protected]
munity environments in which colleges are located would still create drinking problems among college students. In 2003, the Centers for Disease Control and Prevention conducted the Youth Risk Behavior Survey,4 a national random-sample survey of high school students. Results of that survey indicated that, of the over 14 million high school students in the United States, 1 million drank five or more drinks on an occasion at least six times in the past 30 days. If a 170-pound man drank five or more drinks in a 2-hour period on an empty stomach, he would reach a blood alcohol level of 0.08% and would be considered legally intoxicated in every state.5 The typical high school female who weighs less would reach even higher blood alcohol content. Compared to nondrinking students, high school youth who engage in this pattern of frequent drinking to intoxication disproportionately engage in numerous behaviors that pose risk to themselves and others. In the month prior to the survey, they were much more likely to: ● ● ● ● ● ● ● ● ● ● ●
Drive after drinking (61% vs 0%) Ride with a drinking driver (80% vs 13%) Never wear safety belts (18% vs 4%) Carry a gun (24% vs 2%) Be injured in a fight (17% vs 2%) Use marijuana (71% vs 6%) and cocaine (22% vs 4%) Be forced to have sex (18% vs 3%) Have had sex with six or more partners (32% vs 3%) Have been or made someone pregnant (13% vs 2%) Earn mostly D’s and F’s in school (13% vs 4%) Have been injured in a suicide attempt (10% vs 1%)4
The average age when youth start to drink may be declining in the United States.6 Yet the younger people are when they begin to drink, the more likely they are to engage in dangerous drinking practices both in high school4 and college.4,7,8 High school students who began drinking prior to age 13 were seven times more likely to be frequent heavy drinkers (more than five drinks per occasion, more than six times per month) in high school than those who waited until age ⱖ17 to start drinking.4 According to the National College Alcohol Survey among college students aged ⱖ18, those who were first intoxicated before age 13—relative to those first intox-
Am J Prev Med 2004;27(3) © 2004 American Journal of Preventive Medicine • Published by Elsevier Inc.
0749-3797/04/$–see front matter doi:10.1016/j.amepre.2004.06.009
261
icated at age ⱖ19 —were three times more likely to be alcohol dependent in college (8% of drinkers in college are alcohol dependent); 1.6 times more likely to drive after consuming five or more drinks and to ride with a driver who was high or drunk; twice as likely to be so seriously injured after drinking that they required medical attention; and twice as likely to have unplanned and unprotected sex.7,8 These relations with risky behaviors among college students were observed even after controlling for age, gender, race/ethnicity, marital status, alcohol dependence, parental drinking history, and age of first cigarette and marijuana use. Furthermore, although a higher percentage of 18- to 24-year-old college students drink heavily and drive under the influence than same-aged persons not in college, there are so many more young people not in college that they actually account for more alcoholrelated problems and deaths than the drinking college students.2 Thus, there is a clear need to change the drinking culture not only in colleges but also in surrounding communities. Environmental interventions implemented in comprehensive community programs have been found to reduce drinking- and alcohol-related assault injuries, motor vehicle crashes, and deaths9 –12 among high school– and college-aged youth. Typically, these community interventions involve multiple departments of city government, concerned private citizens and organizations, and multiple levels of education and law enforcement programs. In this issue, the article by Weitzman et al.13 examining comprehensive college/community environmental interventions is the first to identify that this type of intervention, if vigorously pursued, can reduce drinking problems specifically among college students. It can also reduce secondhand effects of alcohol perpetrated on other college students by students who engage in excessive college drinking. This careful and rigorous evaluation is the first to show positive benefits of interventions across entire college populations, not just select subgroups of students. These findings are timely because there are no indications of reductions in college drinking in the past decade, and after 15 years of decline, alcohol-related traffic deaths among 18- to 24-year-olds have increased each year since 1997.14 Future research projects should explore (1) specifically what types of interventions in these partnerships can achieve the greatest declines; (2) whether, if augmented by widespread screening and counseling programs, additional reductions can be achieved; and (3) whether people attending colleges with these campus community interventions will be less likely to exhibit drinking problems not just while in college but after they graduate. In addition, whether campus community interventions reduce problems among college-age people who are not students, but live in these college communities needs to be tested. 262
In a related article in this issue by Miller et al.,15 comparisons were made between the binge drinking results from the 1999 and 2001 Behavioral Risk Factor Surveillance System (BRFSS) survey (n ⫽353,371) and the National Survey on Drug Use and Health (NSDUH) (n ⫽87,145). The BRFSS is a random-digit-dial telephone survey with response rates of 56.7% in 1999 and 52.7% in 2001, while the NSDUH is a national in-home survey conducted by trained interviewers that includes use of an audio computer-assisted self-interview survey. The NSDUH achieved a 68.6% response rate in 1999 and 73.3% in 2001. There was good correlation between state-specific binge drinking estimates from the two surveys, Pearson correlation coefficient of r⫽0. 82, and similarities in sociodemographic characteristics of binge drinkers. However, in 1999 and 2001, the BRFSS identified only 14.8% and 14.6% of respondents as binge drinkers, compared to 21.4% and 21.7% in the NSDUH. Focusing only on phone owners in the NSDUH did not eliminate the disparity. Miller et al.15 note that the computer-assisted selfinterviews and the in-person survey approach may help improve the willingness of adults to self-report binge alcohol use. They appropriately called for testing new approaches to increase reporting of binge drinking and response rates. Pre-survey notification by mailing or media, modest financial reimbursement for time spent being interviewed, and greater emphasis on the anonymity of random-digit-dial surveys and the importance of accurate responses might increase both response rates and reports of binge drinking. While that might produce a temporary disruption in tracking the drinking trends over time, obtaining more accurate data would be beneficial. Also short callback surveys of nonrespondents to make comparisons with respondents could help assessments of the survey’s generalizability. The National Advisory Council of the NIAAA has recently defined binge drinking as five drinks for men and four for women over a 2-hour period. Questions about the duration of drinking occasions would strengthen the measurement of binge drinking in both surveys. Because the BRFSS contained many questions on related risky behaviors (e.g., driving after drinking, safety belt use, fighting, carrying weapons, and unprotected sex), it is a very valuable national resource whose usefulness would be enhanced by the suggested changes. Both the BRFSS and the NHSDUH would also be strengthened by questions used by Weitzman et al.13 in the “A Matter of Degree” evaluation that assesses secondhand effects of drinking. Without such questions, the considerable negative effects of binge drinkers’ behavior on other people cannot be fully documented and monitored over time.
American Journal of Preventive Medicine, Volume 27, Number 3
References 1. National Institute on Alcohol Abuse, Alcoholism National Advisory Council. A call to action: changing the culture of drinking at U.S. colleges. Bethesda MD: National Institutes of Health, 2002 (NIH 02-5010). 2. Hingson R, Heeren T, Zakocs R, Kopstein A, Wechsler H. Magnitude of alcohol-related mortality and morbidity among U.S. college students ages 18 –24. J Stud Alcohol 2002;63:136 – 44. 3. Larimer M, Cronce J. Identification, prevention and treatment: a review of individual-focused strategies to reduce problematic alcohol consumption by college students. J Stud Alcohol 2002;14(suppl):148 – 64. 4. Grunbaum J, Kann L, Kindum S, Williams B, Ross R, Koelbe L. Youth Risk Behavior Surveillance—United States, 2003. MMWR Morb Mortal Wkly Rep 2003;51:1– 64. 5. National Highway Traffic Safety Administration. BAC Estimator (computer program). Springfield VA: National Technical Information Service, 1992. 6. Substance Abuse and Mental Health Services Administration. Results from the 2002 National Survey on Drug Use and Health. Rockville MD: National Findings Office of Applied Studies, U.S. Department of Health and Human Services, 2003 (NHSDA Series H-22, DHHS SMN 03-3836). 7. Hingson R, Heeren T, Zakocs R, Winter M, Wechsler H. Age of first intoxication, heavy drinking, driving after drinking and risk of unintentional injury among U.S. college students. J Stud Alcohol 2003;64:23–31.
8. Hingson R, Heeren T Winter M, Wechsler H. Early age of first drunkenness as a factor in college students’ unplanned and unprotected sex attributable to drinking. Pediatrics 2003;111:34 – 41. 9. Hingson R, McGovern T, Howland J, Heeren T, Winter M, Zakocs R. Reducing alcohol-impaired driving in Massachusetts: the savings lives program. Am J Public Health 1996;86:791–7. 10. Holder H, Gruenewald PJ, Ponici WR, et al. Effects of community-based interventions on high risk driving and alcohol-related injuries. JAMA 2000;284:2341–7. 11. Wagenaar A, Murray D, Gehan J, et al. Communities mobilizing for change: outcomes from a randomized community trial. J Stud Alcohol 2000;161:85–94. 12. Hingson R, Howland J. Comprehensive community interventions to promote health: implicatios for college-age drinking problems. J Stud Alcohol 2002;14(suppl):226 – 40. 13. Weitzman ER, Nelson TF, Lee H, Wechsler H. Reducing drinking and related harms in college: evaluation of the “A Matter of Degree” program. Am J Prev Med 2004;27:187–96. 14. National Highway Traffic Safety Administration. Traffic safety facts 2002: alcohol. Washington DC: U.S. Department of Transportation, 2002. 15. Miller JW, Gfroerer JC, Brewer RD, Naimi TS, Mokdad A, Giles WH. Prevalence of adult binge drinking: a comparison of two national surveys. Am J Prev Med 2004;27:197–204.
Am J Prev Med 2004;27(3)
263